Select the Right Claims for a Workers’ Comp Claim Audit Category Claim Audits & File Review

 

Selecting the right claims for a workers’ comp claim audit can make your time much more efficient and effective. Hello my name is Michael Stack and i am the CEO of Amaxx and today i want to give you some tips in order to help you select the right claims for an upcoming workers’ comp claim audit. I want to give you some basic criteria and some special; tips for you to go deeper into selecting these right claims. So, here’s the criteria, the first set of criteria is claims greater than $25,000. So as you’re looking through your loss runs the way that i always do it, the way i recommend is, grab a highlighter and go through your loss runs and you can just select those you take a look through them you’re like okay that’s that’s a good one the claim’s greater than 25 000. Let’s go through this and obviously depending on the number of claims that you have you can adjust some of these number dollar values up or down to be what’s right for you. That’s a good place to start.

Out of Bounds Medical Only Claims

Another good piece of basic criteria is out of bounds or what i like to call ‘out of bounds medical only claims’ so you’re looking at a claim and you’re like what is going on with this thing you know it’s got a huge this is a medical only deal but the the amount paid is really high and the reserves are really high,what is going on here this seems just kind of out of bounds again take your highlighter highlight that one for one that you want to look in your audit.

Open Claims

Another piece of criteria here is ones that are of tips of ones that you want to you want to grab or you only want to grab open claims so only open claims there’s some value or there can be some value in auditing closed claims as far as what happened and best practices et cetera but really you’re going to get the most bang for your buck if you only audit open claims again this speaks to the idea of of out of bounds medical only ones claims that have large reserves so why is the reserve on this thing so high maybe the paid is not very high but the reserve is really high you know or you’re just looking at it and you’re like yeah we gotta y that’s the one we gotta we gotta put in our audit so any open claims with large reserves medical onlys that are open for greater than six months so again that speaks to the out of bounds medical only this thing is a medical only it’s a reasonably small medical only but it’s all it’s open for longer than six months what’s going on here this is something we need to check into

Reserve Authority

Another piece here to look at is your azure reserve authority and so what will happen with this is the adjuster will have a reserve authority amount that they can go up to let’s say you know 25 000 or they can go up to you know 50 000 without having to get approval so their reserve authority they can go up to a certain dollar amount so if you see that that if you’re reserved authority in your scenario but the claim is reserved at say 24,9 and the reserve authority is 25 000. or the claim is reserved at you know 49.9 and the reserve authority is 50 000. that’s a pretty big red flag that you’re like there’s there’s something going on there that the adjuster just didn’t want to ask for greater reserve authority but they know that there’s a piece so you want to take a look at one of those claims that’s a red flag kind of an out of bounds red flag marker that you want to make sure that you’re taking a look

Open Claim But There’s No Action

The last piece is that if there’s an open claim but there’s no action nothing’s been paid on it there’s really nothing happening on it and it’s been open for greater and that that’s been open for greater than six months so it’s been about six months since there’s no action on this game so what what’s happening why isn’t this thing closed let’s take a look at this and let’s get a better understanding in our audit of how we can now improve maybe the course or the path of this of this claim as i said if you can select the right claims take your highlighter out use this criteria as far as selecting this right claims it can make your time spent doing these audits much more efficient and much more effective again my name is Michael Stack and Stack of Amax remember your work today workers compensation can have a dramatic impact on your company’s bottom line but it will have a dramatic impact on someone’s life. So be great.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.

Contact: [email protected].

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